No nurse relishes the prospect of telling a patient that their procedure or operation has had to be cancelled. Avoiding this was one of the main incentives of coronary care charge nurse Nick Mills who, in 2003, set up a nurse-led elective cardioversion service at Addenbrooke's Hospital in Cambridge.
'We had a huge amount of people on the waiting list. Traditionally, a bed is booked in CCU to carry out elective cardioversions, but if that bed in filled, you have to cancel,' he explains.
Back in March 2003 there was an average 18 week wait for the procedure,with 50 pople on the waiting list. The hospital was receiving regular complaints and there were also negative implications for patients' health - the longer a patient remains in atrial fibrillation (AF), the less likely it is that a cardioversion will successfully revert their arrythmia back to sinus rhythm (SR).
Coronary care staff at the hospital realised that all these problems could be solved by implementing a nurse led service, led by a single nurse who would carry out a patient's pre-admission, admission and discharge procedure, as well as perform the actual cardioversion. Nick was appointed to set up such a service in April 2004 and given 30 hours a month to do so, alongside his work in other areas of the hospital's coronary care department. Ten patients a month are booked in and the session takes place in the day surgery department.
A patient's international normalised ratio (INR) results are monitored, as these measure the blood clotting rate of a patient on warfarin therapy. Patients are booked in for a cardioversion once these are within range. A pre-assessment - including ECG, blood tests, patient education and consent - is then carried out by Nick.
The patient's warfarin dosage is titrated according to their INR results over the telephone the same evening if required. 'If a patient is cancelled due to being in sinus rhythm or an out of range INR, I have worked really hard to make sure that another patient was booked in at short notice, so as not to lose the slot,' says Nick.
The procedure takes place five days after pre-assessment in day surgery - the length of stay is a mere four hours from admission to discharge, compared to sevens hour before the nurse-led service existed.
Nick was already trained in defibrillation and advanced life support as a staff nurse, shadowing medical staff in order to learn about performing cardioversions. Although an anaesthetist attends each cardioversion, Nick has run the service single-handedly. As the service was one of the first in the UK, Nick had no formal training to undergo (he has now developed competencies for his predecessor) but he did visit an existing cardioversion service - something he recommends to any nurse looking to set up a similar service. 'When I started I had problems but all these were answered by looking at someone else's service,' he admits.
Two and a half years later (October 2006), the service is a clear success. There is no waiting list and complaint letters have been replaced by letters and emails praising the service and thanking Nick for his help. As well as quicker treatment, patients are praising the high standard of pre-procedure information, which they say lowers their anxiety, as well as the continuity or care that Nick's role provides.
Although Nick is currently undertaking a secondment at PapworthHospital, the service continues to flourish and a colleague, trained up by Nick, has now taken over. Nick hopes that the trust will support his colleague to develop the service in the future. One idea Nick would like to see implemented is a nurse-led follow-up clinic, as currently patients have to wait six months for medical review.
He believes the potential for nurses wanting to set up and run a similar service is huge. 'When I started there were only a few services like this around the UK. I was swamped by nurses getting in touch. Now there are already many more up and running.'
The benefits ofa nurse-led elective cardioversion service
- A time and cost-effective service - a shorter procedure and pre-assessment, with less wasted slots and cancellations
- Better patient education and continuity of care - and a resultant reduction in patient anxiety
- A projected date for the procedure can be provided at the time of referral
- Patients receive earlier treatment, thus increasing the success rate of the cardioversion
- The doctor's time is freed up and nurses gain the opportunity to develop new skills and increase autonomy